![logo]()
examination of the internal structures
1. an ophthalmoscope is used to inspect the fundus, including the retina, choroids, optic-nerve disc, macula, fovea centralism, and retinal vessels
2. the examiner inspects the size, color, and clarity of the disc, the integrity of the vessels, and the appearance of the macula and fovea and looks for retinal lesions
3. performed in a darkened room
4. the client's eye glasses are removed (contact lenses are left in place)
NCLEX 336
equipment
-ophthalmoscope
-mydriatic (causing pupillary dilation) drops to dilate the pupil
procedure
1. apply mydriatic drops (contraindicated in patients with closed-angle glaucoma)
2. as pupil dilation occurs, darken the room
3. instruct patient to remain still and focus on a stationary object
4. examiner uses ophthalmoscope to view internal eye structure
5. document findings
teaching
1. explain procedure
2. instruct patient that effects of the drops will last no longer than 1 hour
3. patient requires sunglasses when outside or in brightly lit room until pupils return to normal size
4. examiner discusses results with patient and encourages corrective measures
AHN 608 -nursing responsibility to educate, assist, counsel, and prevent complications
-comprehensive approach to care can help the patient successfully adjust to home, work, and society
risk for injury r/r new environment
-orient to the patient to the environment
-use therapeutic touch
-avoid loud sounds that may startle the patient
-use protective devices, such as side rails and canes
-alter surroundings to afford safety (clear passageways, nonslip rugs, etc)
AHN 610
1. when speaking , use a normal tone of voice
2. alert client when approaching
3. orient client to environment
4. use focal point and provide further orientation from focal point
5. allow client to touch objects in room
6. use clock placement of foods on meal tray to orient client
7. promote independence as much as possible
8. provide radios, televisions, and clocks that give the time orally, or provide a Braille watch
9. when ambulating, allow the client to grasp the nurse's arm at the elbow; keep your arm close to the body so that the client can detect the direction of movement
10. instruct the client to remain one step behind the nurse when ambulating
11. instruct the client in the use of the can used for the blind client, which is differentiated from other canes by its straight shape and white color with red tip
12. instruct the client that the cane is held in the dominant hand several inches off the floor
13. instruct the client that the cane sweeps the ground where the client's foot will be placed next to determine the presence of obstacles
NCLEX 767 -changes in accommodation, resulting in increased difficulty focusing on close objects (presbyopia), which leads to difficulty reading or doing other close work [d/t crystalline lens of the eye hardening and becoming too large for the eye muscles]
-decreased color perception and discrimination, particularly with shades of blue, green, and violet [r/t crystalline lens loses some of tis transparency and becomes more opaque]
-poor adaptation to changes in light, resulting in "night blindness" and increased sensitivity to glare due to increased opacity of the lens and decreased pupil size [pupils become smaller and decrease the amount of light that reaches the retina, resulting in a need for brighter lighting for reading]
-alterations in depth perception, leading to increased risk of falls [ARMD contributes to impaired vision]
-decreased secretion of tears, resulting in complaints of dryness or pruritus, which leads to a high risk for irritation of the cornea
-increased incidence of moving particles or "floaters" that interfere with visually based tasks
-increased incidence of eye disorders, including cataracts, retinal detachment, macular degeneration, and glaucoma [lens proteins are vulnerable to biochemical changes and exposure to UV light, resulting in cataract development]
AHN 607 -avoid eye straining
-avoid rubbing or placing pressure on the eyes [avoid lying on the side of the affected eye on the night after surgery]
-avoid rapid movements, straining, sneezing, coughing, bending, vomiting, or lifting objects of more than 5 lbs
-take measures to prevent constipation [straining with elimination increases IOP]
-follow instructions for dressing changes and prescribed eye drops and medications [wear clean latex or vinyl gloves]
-wipe excess drainage or tearing with a sterile wet cotton ball from the inner to the outward can thus
-use an eye shield at bedtime [or specified hours]
-if a lens implant is not performed accommodation is affected and glasses must be worn at all times
-cataract glasses act as magnifying glasses and replace central vision only
-because cataract glasses magnify, objects appear closer; therefore the client needs to accommodate, judge distance, and climb stairs carefully
-contact lenses provide sharp visual acuity, but dexterity is needed to insert them
-contact the HCP for any decrease in vision, severe eye pain, or increase in eye discharge
NCLEX 768
[instruct family to remove unnecessary furniture and pick up objects that may be blocking pathways]
[does not correct nearsightedness or farsightedness; corrective lenses are still needed for these problems after surgery]
AHN 619
-teach patient and family proper hygiene and eye care techniques to ensure that medications, dressings, and surgical sound are not contaminated during necessary eye care
-teach patient and family about s/s of infection and when and how to report those to allow early recognition and treatment
-instruct patient to comply with post operative restrictions on head positioning, bending, coughing, and Valsalva's maneuver to optimize visual outcomes and prevent increased IOP
-instruct patient to instill eye medications using aseptic techniques and to comply with prescribed eye medication routine to prevent infection
-instruct patient to monitor patient pain and take prescribed medication for pain as directed and to report pain not relieved by prescribed medications
-stress the importance of continued follow-up as recommended to maximize potential visual outcomes
AHN 620 -early corrective intervention
-one of four procedures
laser photocoagulation burns localized tears or breaks in the posterior portion of the eyeball, eventual sealing the tear or break
cryotherapy freezes the borders of a retinal hole with a frozen-tipped probe
-probe is applied to the scleral surface directly over the retinal hole area
-the hole seals when the resultant inflammatory process produces scarring
electrodiathermy burns a retinal break using an ultrasonic probe
-probe is applied to the scleral surface directly over the retinal break
-sealing occurs from the resultant inflammatory and scarring process
scleral buckling an extraocular surgical procedure that involves indenting the globe so the pigment epithelium, choroid, and sclera move toward the detach retina
-not only helps seal retinal breaks, but also helps relieve inward traction on the retina
-surgeon sutures a silicone implant against the sclera, causing the sclera to buckle inward
-surgeon may may place an encircling band over the implant if there are multiple retinal breaks, if the surgeon cannot locate suspected breaks, or if there is widespread inward traction on the retina
-if present, sub retinal fluid amy be drained by inserting a small-gauge needle to facilitate contact between the retina and the buckled sclera
-sleral buckling is usually accomplished with the patient under coal anesthesia
-discharged on the first postoperative day, or as an outpatient procedure
pneumatic retinopexy intraocular procedure that involves the injection of a gas into the vitreous cavity to form a temporary bubble that closes retinal breaks and places pressure on the separated retinal layers
-bubble is temporary and is combined with treatments of laser photocoagulation or cryotherapy
-for several weeks the patient must position the head in a forward position so the bubble is in contact with the retinal break
AHN 622
1. draining fluid from the sub retinal space so that the retina can return to the normal position
2. sealing retinal breaks by cryosurgery, a cold probe applied to the sclera, to stimulate an inflammatory response leading to adhesions
3. diathermy, the use of an electrode needle and heat through the sclera, to stimulate an inflammatory response
4. laser therapy, to stimulate an inflammatory response and to seal small retinal tears before the detachment occurs
5. scleral buckling, to hold the choroid and retina together with a splint until scar tissue forms and closes the tear
6. insertion of gas or silicone oil to promote reattachment; these agents float against the retina to hold it in place until healing occurs
NCLEX 769 -reinforce activity restrictions as ordered to prevent injury to the eye
-use safety measures until able to ambulate safely
-announce presence
-avoid bending, lifting, and straining for approximately 1 month to prevent increases in IOP or suture tension
-regular postoperative visits
-report any severe or progressive pain immediately
-report erythema, loss of vision, or photophobia (corneal rejection)
-asepsis during dressing changes
-wash hands thoroughly before any contact with eye area
-avoid use of irritants (powder perfume, propellants can cause sneezing and displacement of sutures)
-do not rub eye area (contamination and displacing sutures)
-tv ok, reading limited (side-to-side may loosen sutures)
-eyepatch or metal eyecup shield (applied snugly to inhibit the blink reflex and allow the eye to rest; at night to protect the eye from trauma)
AHN 630
1. the eye is covered with a pressure patch and protective whiled that is left in place for 1 day
2. do not remove or change the dressing without a HCP's prescription
3. monitor the VS
4. monitor the LOC
5. monitor the eye dressing
6. position the client with the head elevated and on the nonoperative side to reduce IOP
7. orient the client frequently
8. monitor for complications of bleeding, wound, leakage, infection, and tissue rejection
9. instruct the client on how to apply a patch and eye shield
10. instruct the client to wear the eye shield at night for 1 month and whenever around small children or pets
11. advise the client no to rub the eye
NCLEX 771 -if wears a hearing aid, make certain it is in place, turned on, and functioning properly
-get attention by raising an arm or hand
-ask permission to turn of tv or radio or turn down volume
-start with light on your face; will help person speech read
-face the person when speaking
-speech reading is a skill that not all hearing impaired are capable of achieving; do not assume all can lip read
-speak clearly, but do not over accentuate words
-speak in a normal tone; do not shout or raise the pitch of voice; shouting overuses normal speaking movements and may cause distortion and be too loud for the person with sensorineural damage; if the persona has conductive loss only, sometimes making voice louder w/o shouting is helpful
-if the person does not seem to understand what is said, express it differently; some words are difficult to see in speech reading, such as white or red
-move closer to the person and toward the better ear if the person does not hear you
-write out proper names or any statement that you are not sure was understood
-do not eat, drink, chew gum, or cover the mouth when talking to a person with limited hearing
-observe for inattention that may indicate tiredness of lack of understanding
-use phrases rather than one-word answers to convey meaning; state the major topic of the discussion first and then give details
-do not show annoyance by careless facial expression; use normal facial expressions; people who are had of hearing depend more on visual clues for acceptance
-encourage the use of a hearing aid if the person has one; allow the person to adjust it before speaking
-if in a group, repeat important statements and avoid asides to others in the group
-avoid the use of the intercommunication system as this may distort sound and cause poor communication
-do not avoid conversation with a person who has hearing loss
AHN 633
-using written words if the client is able to see, read, and write
-providing plenty of light in the room
-getting the attention of the client before beginning to speak
-facing the client when speaking
-talking in a room without distracting noises
-moving close to the client and speaking slowly and clearly
-keeping hands and other objects away from the mouth when talking to the client
-talking in normal volume and lower pitch, since shouting is not helpful and higher frequencies are less easily heard
-rephrasing sentences and repeating information
-validating with the client the understanding of statements made by asking the client to repeat what was said
-using lip-reading
-encouraging the client to wear glasses when talking to someone to improve vision for lip reading
-using sign language, which combines speech with hand movements that signify letters, words, or phrases
-using telephone amplifiers
-using flashing lights that are activated by ringing of the telephone or doorbell
-using specially trained dogs that help the client to be aware of sound and to alert the client to potential dangers
NCLEX 773 1. inform the client that hearing is initially worse after the surgical procedure because of swelling and that no noticeable improvement in hearing may occur for as long as 6 weeks
2. inform the client that the Gelfoam ear packing interferes with hearing but is used to decreased bleeding
3. assist with ambulating during the first 1 to 2 days after surgery
4. provide side rails when the client is in bed
5. administer antibiotics, antivertiginous, and pain medications as prescribed
6. monitor for facial nerve damage, weakness, changes in tactile sensation, changes in taste sensation, vertigo, nausea, and vomiting
7. instruct the client to move the head slowly when changing positions to prevent vertigo
8. instruct the client to avoid persons with upper reparatory tract infections
9. instruct the client to avoid using small objects (cotton-tipped applicators) to clean the external ear canal
10. instruct the client to avoid rapid, extreme changes in pressure caused by quick head movements, sneezing, nose blowing, straining, and changes in altitude
11. instruct the client to avoid changes in middle ear pressure because they could dislodge the graft or prosthesis
NCLEX 777 systemic antibiotics
anti emetics
antivertiginous medications
NCLEX 777
antibiotics
dimenhydrinate (Dramamine) - vertigo
meclizine (Antivert) - vertigo
parenteral fluids - nausea and vomiting
AHN 639
carbamide peroxide (Debrox)
cerumen removal
colistin, neomycin, hydrocortisone, and thonzonium (Coly-Mycin S Otic)
antibiotic-steroid-detergent sued for susceptibe decease of external auditory canal, mastoidectomy, and otitis media fenestration
triethanolamine polypeptide oleate (Cerumenex)
cerumen removal
amoxicillin trihydrate (Amoxil)
systemic penicillin antibiotic used in acute otitis media
cefeclor (Ceclor)
second-generation cephalosporin used to treat amoxicillin-resistant otitis media
meclizine hydrochloride (Antivert)
anticholinergic antihistamine that acts as antiemetic, anti vertigo agent; treatment and prophylaxis; possible effective for disease affecting vestibular system
dimenhydrinate (Dramamine)
anticholinergic antihistamine used in treatment of vertigo
antipyrine and benzocaine (Auralgan)
analgesic; local anesthetic; used for otitis media; adjunct to cerumen removal
acetic acid (VoSol hydrochloride otic)
antibacterial, antifungal, astringent; used for superficial infections of external auditory canal
trimethoprim-sulfamethoxazole (Bactrim)
systemic antibacterial; used for acute otitis media; no sulfonamide allergy
polymyxin B, neomycin, bacitracin, and hydrocortisone (Cortisporin)
antibiotic and steroid used in the same way as Coly-Mycin S; used to treat swimmer's ear
AHN 637 1. also called endolymphatic hydrous and refers to dilation of the endolymphatic system by over production or decreased reabsorption of endolymphatic fluid
2. characterized by tinnitus, unilateral sensorineurla hearing loss, and vertigo
3. symptoms occur in attacks and last for several days, and the client becomes totally incapacitated during the attacks
4. initial hearing loss is reversible but as the frequency of attacks continues, hearing loss becomes permanent
priority nursing intervention si instituting safety measures
NCLEX 777
-chronic disease of the inner ear characterized by recurrent episodes of vertigo, progressive unilateral nerve deafness, and tinnnitus
-most common in women between 30 and 60 years of age
-cause is unknown, although occasionally the condition follows middle-ear infection or trauma to the head
-increase in endolymph fluid, either form increased production or decreased absorption
-this causes increased pressure win the inner-ear labyrinth
-attacks of severe vertigo, tinnitus, and progressive deafness result from this increased pressure
-usually one ear only is involved
AHN 641 